Healthcare Provider Details

I. General information

NPI: 1639542269
Provider Name (Legal Business Name): LATRICE BURGOS BA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2015
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER BLVD
CHESTER PA
19013-3902
US

IV. Provider business mailing address

518 EAST 23RD STREET
CHESTER PA
19013
US

V. Phone/Fax

Practice location:
  • Phone: 610-619-8420
  • Fax:
Mailing address:
  • Phone: 484-557-3008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: